GI Bleeding =========== þ Glasgow-Blatchford Scale for sending GI bleeders home [Stanley, A. J., D. Ashley, et al. (2009). "Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation." Lancet 373(9657): 42-47.] BACKGROUND: Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low- risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals. METHODS: Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper- gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients. FINDINGS: Of 676 people presenting with upper- gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77- 0.84]), which in turn was better than the admission Rockall score (0.70 [0.65- 0.75]). When introduced into clinical practice, 123 patients (22%) with upper- gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001). INTERPRETATION: The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources. Score value Blood urea (mmol/L) 6·5–7·9 2 8·0–9·9 3 10·0–25·0 4 >25·0 6 Haemoglobin for men (g/L) 120–129 1 100–119 3 <100 6 Haemoglobin for women (g/L) 100–119 1 <100 6 Systolic blood pressure (mm Hg) 100–109 1 90–99 2 <90 3 Other markers Pulse =100/min 1 Presentation with melaena 1 Presentation with syncope 2 Hepatic disease 2 Cardiac failure 2 þ ^ BUN over Cr sign of UGI rather than lower GI bleed even if NG aspirate negative þ Differential diagnosis of melena includes endocarditis. þ Variceal Bleeding: - IV somatostatin or its analogue, octreotide, is more effective and has fewer side effects than vasopressin; dose is 50 micrograms per hour IV. (Scientific American Medicine, 2/97) - American College of Gastroenterology says: + start ocreotide (50 ug bolus and 50 ug an hour), continue for 5 days + endoscopic sclerosis or ligation ASAP + start beta blocker (recommend nadolol 40 mg daily) and a nitrate (isosorbide mononitrate 20 mg BID) when stable - Vasopressin has serious side effects: 9% of patients will have a major complication, and 3% will have a fatal complication from this medication. Though several studies suggest some benefit from its use in variceal bleeding, it does not appear to decrease overall mortality. Therefore some say that its use should be limited to the exsanguinating patient with suspected variceal bleeding, for whom endoscopy is unavailable. Ref: Rosen 3rd ed. p 1526 - What is the mortality from complications of a Sengstakken- Blakemore tube? 14% of patients will have a major complication from the use of this tube, which is used to control variceal bleeding, and 3% of patients will have a fatal complication. Ref: Rosen 3rd ed. p 1521 - There is reportedly a 50% incidence of spontaneous bacterial peritonitis (SPB) in variceal bleeding. Unclear if this is from bacterial contamination of the varices primarily or from instrumentation (EGD), but standard is to do a 50cc peritoneal tap and send for studies, then 7 days of Cipro or Levaquin. (per David Limauro, 9/03) þ Surgery for GI Bleeding - The mortality of emergency surgery for GI bleeding is 23%. - Surgery should be considered for patients who require more than 5 units of blood within the first 4-6 hours, or when 2 units of blood is needed every 4 hours after replacing initial losses to maintain cardiac output. Ref: Rosen 3rd ed. p 1526 þ Equilibration of H/H after bleeding þ GI bleeding and NG lavage: - If a patient with bloody stool has clear fluid returned by nasogastric suction, can we be assured that the bleeding is coming from below the ligament of Treitz (a lower GI bleed)? No. It is very possible in this case that there is bleeding in the duodenum that is not flowing backwards through the pylorus into the stomach. However, if non-bloody bilious fluid returns via nasogastric suction, then this is almost certainly a lower GI bleed (unless the bleeding is intermittent). The presence of bile assures that fluid from the duodenum has been sampled. Ref: Rosen 3rd ed. p 1521 - Other than continuing bleeding, what can cause nasogastric lavage fluid to continue to return with a pink color despite several hundred mL's of irrigation? If clots are present in the stomach which are too big to fit in through the holes of the nasogastric tube, the clots may remain and continue to stain the lavage fluid pink. For this reason, some authors have suggested the use of an Ewald tube for gastric lavage in patients with a GI bleed. Ref: Rosen 3rd ed. p 1521-2. þ Hemoccult and Gastrocult testing and melena: - Which of the following can decrease the sensitivity of guaiac cards: red wine, red chili powder, cherry gelatin, or spaghetti sauce? All of the above, as well as a number of other agents, can decrease the sensitivity of guaiac cards. Ref: Rosen 3rd ed. p 1520. - Melena usually signifies an upper GI bleed, but this is very dependent on the transit time of the stool. 23-43% of patients with a lower GI bleed will have black, tarry stools. Ref: Rosen 3rd ed. p 1519 - Internet Discussion: The rule I have always used is that the absense of blood and the presence of bile in the aspirate *does indeed* rule out an UGI source of bleeding. It is true that standard hemoccult cards are inactivated by gastric acid and may thus be falsely negative. However a *gastroccult* (Smith-Klien I believe) card is markeded and does not have this limitation.In most cases, however, I do not check for the presence of occult blood in the GI aspirate unless I'm unsure whether a dark return represents coffee grounds or not. In the presence of a clear aspirate the gastroocult adds no new information. H. Louzon, M.D. ----------------------------------------------------------------------- It is interesting that a significant portion (1/4) of patients presenting with melena do not have a readily identifiable source on upper endoscopy (2). Many of these patients have a source of bleeding identified in the right colon. Nevertheless, *objective* measures of stool color do indeed confirm that 'true' melena has a high correlation with bleeding from above confirming what, I think, is most people's experience (3). In the *absence* of melena the appearence of the gastric aspirate *does* appear to have a correlation with the severity of the bleed and need for intervention (4,5). H. Louzon MD (1) Ritter DM, Rettke SR, Hughes RW Jr, Burritt MF, Sterioff S, Ilstrup DM Placement of nasogastric tubes and esophageal stethoscopes in patients with documented esophageal varices. Anesth Analg 1988 Mar;67(3):283-5 (2) Ibach MB, Grier JF, Goldman DE, LaFontaine S, Gholson CF Diagnostic considerations in evaluation of patients presenting with melena and nondiagnostic esophagogastroduodenoscopy. Dig Dis Sci 1995 Jul;40(7):1459-62 Proper evaluation of patients with melena and nondiagnostic esophagogastroduodenoscopy is comparatively undefined. We sought to determine the percentage of patients with melena and nondiagnostic upper endoscopy and assess the yield of further evaluation. Of 209 patients presenting with melena, 180 underwent esophagogastroduodenoscopy as the initial study, which was nondiagnostic in 43 cases (24%). Further evaluation was pursued in 30. A presumed source of melena was found in 11 patients (37%), identified by colonoscopy in seven, bleeding scan in three, and barium enema plus flexible sigmoidoscopy in one. Nearly all such defined cases originated from the right colon. Small bowel contrast studies, flexible sigmoidoscopy of barium enema alone, and angiography failed to reveal a source. Our findings suggest that many (24%) patients presenting with melena will have nondiagnostic upper endoscopy; further evaluation reveals a potential source in 37% of this group, with the right colon being the most likely location of pathology; and colonoscopy is the test of choice in this cohort. (3) Zuckerman GR, Trellis DR, Sherman TM, Clouse RE An objective measure of stool color for differentiating upper from lower gastrointestinal bleeding. Dig Dis Sci 1995 Aug;40(8):1614-21 Subjective reporting of the color of blood passed per rectum has been used to predict the location of gastrointestinal bleeding, but the validity of this clinical approach has never been evaluated systematically. In this study we determined the spectrum of patient and physician descriptors used to characterize the color of blood passed per rectum and evaluated prospectively if an objective test of stool color would correlate with or improve upon subjective descriptions in predicting bleeding locations. The objective test employed was a card containing five numbered colors that typify the spectrum of stool blood colors. One hundred twenty patients used 23 different descriptors or terms to verbalize the color of blood they passed per rectum, and in 22% of cases there was a seeming discrepancy between their verbalized color and the color they pointed to on the test card. Patients pointing to card color 4 (the black color) resulted in closer matching to an upper bleeding source than physicians using terminology such as melena or tarry stools. Likewise, patients picking card colors 1 and 2 (the brightest red colors) resulted in closer matching to a coloanorectal bleeding source than physicians using the terms hematochezia or bright red blood per rectum (P < 0.02 for each comparison). The positive predictive value of card color 4 for an upper bleeding source was very high both when patients pointed to this color or when it was determined from the available stool (0.95 and 0.98, respectively). The positive predictive value of card color 1 for lower bleeding was greater for patients selecting this color than for a direct stool comparison (1.00 vs 0.83).(ABSTRACT TRUNCATED AT 250 WORDS) (4) Wara P, Stodkilde H Bleeding pattern before admission as guideline for emergency endoscopy. Scand J Gastroenterol 1985 Jan;20(1):72-8 In a prospective study of 539 patients admitted because of hematemesis and melena the bleeding pattern before admission was compared with the findings obtained on emergency endoscopy and the subsequent clinical course. Ranked in order of prognostic importance, red hematemesis with melena, black hematemesis with melena, and red hematemesis alone increased the probability of massive hemorrhage. Moreover, black hematemesis with melena was the superior predictor of bleeding ulcer, the commonest lesion carrying the risk of massive hemorrhage. In contrast, in patients with melena or black hematemesis alone massive hemorrhage occurred comparatively infrequently. The order of prognostic importance was supported by the transfusion requirement. In screening for a potentially life-threatening ulcer hemorrhage, emergency endoscopy is recommended in patients with black hematemesis with melena or with red hematemesis with or without melena. In patients presenting with black hematemesis or melena alone endoscopy may be postponed to the next convenient daytime. (5) Harland R, Neilson D Criteria for selective admission of patients with haematemesis. J R Soc Med 1992 Jan;85(1):26-8 A retrospective survey of 157 consecutive admissions for haematemesis was carried out in order to determine whether patients at low risk of adverse events could be identified at the time of admission from simple clinical features. In addition to known prognostic factors such as hypotension, tachycardia and anaemia, we studied the character of the vomit classified into altered or frank blood. Death, surgical intervention and transfusion of more than 2 units of blood were defined as 'adverse events'. No adverse event occurred in 37 patients who vomited only altered blood and who did not have melaena, or in 42 patients with a concentration of haemoglobin of 12 g/dl or more who vomited altered blood only. Classification by other prognostic criteria was not as sensitive. These results suggested that patients with haematemesis who have negligible risk of serious sequelae can be identified at an early stage in the course of their disease from simple features of clinical history and examination. Excessive use of resources should be avoided in such patients, and selective admission may be justified. --------------------------------------------------------------- For source of rupture of esophageal varices from NG tubes check the following references: Campbell DE. Complications of NG intubation. Ann Surg 130:113, 1949 Hafner CD et al Complications of NG intubation. Arch Surg 83:147, 1961 Hanselman RC and Meyer RH. Complications of NG intubation. Surg Gynecol Obstet 114:207, 1962 Barry Brenner MD, Brooklyn Hospital --------------------------------------------------------------------- >A GI fellow told me last year of a study published in the 1970s that >demonstrated the minimum amount of swallowed blood predictably causing melena >(60 ml, medical student volunteers). He couldn't remember the journal or >author, however, and after looking high and low for it, I gave up. Does >anyone know of this study? > >James Li, MD >Charity Hospital >New Orleans > Yo, James .... Quite propitiously for the purposes of this discussion, I was in fact a participant in that study ... I do not recall the results of the study, because I frankly enrolled only to avoid my surgical rotation ... However, I think that it nevertheless is incumbent on me to report a rather significant potential confounder in the study .. You see, the research "subjects" (myself and others of the more impoverished sector of my medical school compatriots) were paid not by the hour or by the semester; rather, we were paid actually according to the precise amount of blood we swallowed - dollar per cc - and so we had a trememdous incentive amongst ourselves to maximize the amount of blood each of us could swallow .. We therefore quickly discovered or invented numerous subtle subterfuges by which we could, so to speak, tinker with our organic residue, so that it always worked out that it required higher and higher volumes of blood swallowed to make that blood turn up again on the way out ... needless to say, this introduced a significant distortion in the results .... Anyway, just wanted to let you know, in case you ever manage to "run" that study down ... Yours, CS Charles Steinbruegge, MD Chicago stein@interaccess.com ------------------------------------------------------------------- The study concerning 60 ml of blood causing melena involving medical students drinking blood is: Daniel and Egan. Quanitity of blood required to produce a tarry stool. JAMA 113:2232, 1939. Either the physician who responded that he was involved in this study as a medical student is in his 70's or there is a more recent study. Schiff et al. Observations on the oral administration of citrated blood in man: effect on stools Am J Med Sci 203:409, 1942. This article reflects the fact that stools remain positive for occult blood for 10-14 days after a GI bleed. Barry Brenner MD PhD ------------------------------------------------------------------------ I had a chance today, during my weekly blitz through the library to actually dig up a few articles that I referenced last week. One in particular looked at the risk of inducing GI bleeding by NG insertion in patients with documented varices and end-stage liver disease (1). Although these (75) patients were not actively bleeding at the time, 16% had undergone endoscopic sclerotherapy within the past three months and all had a coagulapthy. Hemmorhage was precipitated in none of these patients. Granted these patients were not actively bleeding and thus the theoretical risk of dislodging a 'clot' overlying a varix was not present. The authors reference another study done on patients with a 'recent episode of UGI bleeding' and found no instances in these 24 cases (2). (Unfortunatley I did not see this later reference until I got home and thus didn't copy it--sometimes the best source of references are the articles themselves as this one escaped my medline search). I took a look ("Just one look...that's all it took was....just one look") at the 1961, 1962 references on case reports of variceal bleeding and decided not to photocopy them. I believe that precipitation of bleeding *can* occur but they are the stuff of case reports. I don't think that patient management should be modified because of the possible occurence of, what seems to be, a relatively rare event. H. Louzon MD (1) Ritter DM, Rettke SR, Hughes RW Jr, Burritt MF, Sterioff S, Ilstrup DM Placement of nasogastric tubes and esophageal stethoscopes in patients with documented esophageal varices. Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Anesth Analg 1988 Mar;67(3):283-5 (2) Lopez-Torres A, Waye JD The safety of intubation in patients with esophageal varices. Am J Dig Dis 1973 Dec;18(12):1032-4